The Great Influenza: The Epic Story of the Deadliest Plague in History

by John M. Barry

What the government didn’t do, vigilantes did. There were the twelve hundred IWW members locked in boxcars in Arizona and left on a siding in the desert. There was IWW member Frank Little, tied to a car and dragged through streets in Butte, Montana, until his kneecaps were scraped off, then hung by the neck from a railroad trestle. There was Robert Prager, born in Germany but who had tried to enlist in the navy, attacked by a crowd outside St. Louis, beaten, stripped, bound in an American flag, and lynched because he uttered a positive word about his country of origin. And, after that mob’s leaders were acquitted, there was the juror’s shout, “I guess nobody can say we aren’t loyal now!” Meanwhile, a Washington Post editorial commented, “In spite of excesses such as lynching, it is a healthful and wholesome awakening in the interior of the country.”

Influenza was a disease spread in crowds. “Avoid crowds” was the advice Krusen and the Philadelphia Board of Health gave. To prevent crowding the Philadelphia Rapid Transit Company had just limited the number of passengers in streetcars.

The incubation period of influenza is twenty-four to seventy-two hours. Two days after the parade, Krusen issued a somber statement: “The epidemic is now present in the civilian population and is assuming the type found in naval stations and cantonments.” To understand the full meaning of that statement, one must understand precisely what was occurring in the army camps.

Influenza is a special instance among infectious diseases. This virus is transmitted so effectively that it exhausts the supply of susceptible hosts.

“Pale Horse, Pale Rider” she described her movement toward death: “She lay on a narrow ledge over a pit she knew to be bottomless . . . and soft carefully shaped words like oblivion and eternity are curtains hung before nothing at all. . . . Her mind tottered and slithered again, broke from its foundation and spun like a cast wheel in a ditch. . . . [S]he sank easily through deeps under deeps of darkness until she lay like a stone at the farthest bottom of life, knowing herself to be blind, deaf, speechless, no longer aware of the members of her own body, entirely withdrawn from all human concerns, yet alive with a peculiar lucidity and coherence; all notions of the mind, . . . all ties of blood and the desires of the heart, dissolved and fell away from her, and there remained of her only a minute fiercely burning particle of being that knew itself alone, that relied upon nothing beyond itself for its strength; not susceptible to any appeal or inducement, being itself composed entirely of one single motive, the stubborn will to live. This fiery motionless particle set itself unaided to resist destruction, to survive and to be in its own madness of being, motiveless and planless beyond that one essential end.”

During the course of the epidemic, 47 percent of all deaths in the United States, nearly half of all those who died from all causes combined—from cancer, from heart disease, from stroke, from tuberculosis, from accidents, from suicide, from murder, and from all other causes—resulted from influenza and its complications. And it killed enough to depress the average life expectancy in the United States by more than ten years.

The most pregnant word in science is “interesting.” It suggests something new, puzzling, and potentially significant.

Almost anything that puts extreme stress on the lung can cause ARDS: near drowning, smoke inhalation, inhaling toxic fumes (or poison gas) . . . or influenzal viral pneumonia. Doctors today looking at pathology reports of lungs in 1918 would immediately designate the condition as ARDS. One pulmonary expert describes ARDS as “a burn inside the lungs.” It is a virtual scorching of lung tissue. When viral pneumonia causes the condition, the immune system toxins designed to destroy invaders are what, in effect, flame in the lung, scorching the tissue.

Most deaths almost certainly did come from secondary bacterial infections, but probably not quite so many as has been assumed. That should, however, be small comfort for those who worry about the next influenza pandemic.

To save lives they needed the answer to at least one of three questions. It was possible that even a single rough approximation of an answer would give them enough knowledge to intervene, to interrupt the disease at some critical juncture. But it was also possible they could learn detailed answers to all three questions and still remain helpless, utterly helpless.

First, they needed to understand the epidemiology of influenza, how it behaved and spread. Scientists had already learned to control cholera, typhoid, yellow fever, malaria, bubonic plague, and other diseases by understanding their epidemiology even before developing either a vaccine or cure.

Second, they needed to learn its pathology, what it did within the body, the precise course of the disease. That too might allow them to ...

Third, they needed to know what the pathogen was, what microorganism caused influenza. This could allow them to find a way to stimulate the immune system to prevent or cure the disease. It was also conceivable that even without kno...

For all the urgency, investigators could not allow themselves to be panicked into a disorderly approach. Disorder would lead nowhere. They began with what they knew and with what they could do.

Certainty creates strength. Certainty gives one something upon which to lean. Uncertainty creates weakness. Uncertainty makes one tentative if not fearful, and tentative steps, even when in the right direction, may not overcome significant obstacles.

Which raises another question: How does one know when one knows? In turn this leads to more practical questions: How does one know when to continue to push an experiment? And how does one know when to abandon a clue as a false trail?

advised, “Whenever you fall, pick up something.” And he often said, “Disappointment is my daily bread. I thrive on it.”

To have any chance in alleviating the devastation of the epidemic required organization, coordination, implementation. It required leadership and it required that institutions follow that leadership.

The best institutions avoid the worst aspects of bureaucracy in two ways. Some are not really institutions at all. They are simply a loose confederation of individuals, each of whom remains largely a free agent whose achievements are independent of the institution but who also shares and benefits from association with others.

Other institutions avoid the worst elements of bureaucracy by concentrating on a clearly defined purpose. Their rules have little to do with such procedural issues as a chain of command; instead rules focus on how to achieve a particular result, in effect offering guidance based on experience.

“I confess I was near to tears, and that there was tightening around my throat. It was death, death in one of its worst forms, to be consigned nameless to the sea.”

NOTHING COULD HAVE STOPPED the sweep of influenza through either the United States or the rest of the world—but ruthless intervention and quarantines might have interrupted its progress and created occasional firebreaks.

In 1918 fear moved ahead of the virus like the bow wave before a ship. Fear drove the people, and the government and the press could not control it.

Albert Camus wrote, “What’s true of all the evils in the world is true of plague as well. It helps men to rise above themselves.”

A decade after the pandemic, a careful and comprehensive scientific review of findings and statistics not only in the United States but around the world confirmed, “In the later stages of the epidemic the supposedly characteristic influenza lesions were less frequently found, the share of secondary invaders was more plainly recognizable, and the differences of locality were sharply marked. . . . [I]n 1919 the ‘water-logged’ lungs”—those in which death came quickly from ARDS—“were relatively rarely encountered.”

The connection between influenza and various mental instabilities seemed clear. The evidence was almost entirely anecdotal, the worst and weakest kind of evidence, but it convinced the vast majority of contemporary observers that influenza could alter mental processes. What convinced them were observations such as these:

Contemporary observers also linked influenza to an increase in Parkinson’s disease a decade later. (Some have theorized that the patients in Oliver Sacks’s The Awakening were victims of the 1918 influenza pandemic.) Many believed that the virus could cause schizophrenia, and in 1926, Karl Menninger studied links between influenza and schizophrenia.

Wilson had influenza, only influenza.

In March 1919 a senior Red Cross official advised district officers to help wherever possible on an emergency basis, because “the influenza epidemic not only caused the deaths of some six hundred thousand people, but it also left a trail of lowered vitality . . . nervous breakdown, and other sequella [sic] which now threaten thousands of people. It left widows and orphans and dependent old people. It has reduced many of these families to poverty and acute distress. This havoc is wide spread, reaching all parts of the United States and all classes of people.” Months after “recovering”

People write about war. They write about the Holocaust. They write about horrors that people inflict on people. Apparently they forget the horrors that nature inflicts on people, the horrors that make humans least significant. And yet the pandemic resonated. When the Nazis took control of Germany in 1933, Christopher Isherwood wrote of Berlin: “The whole city lay under an epidemic of discreet, infectious fear. I could feel it, like influenza, in my bones.”

Yet these men also recognized that whatever each other’s flaws might be, each of them also had strengths, remarkable strengths. Their work was good enough that, even if in error, one could often find in that error something new, something important, something to build upon.

Only a very few saw beyond their own work and were willing to contradict themselves. Park and Williams were among these few. In doing so they demonstrated an extraordinary openness, an extraordinary willingness to look with a fresh eye at their own experimental results.

William Park, Oswald Avery, and Paul Lewis each approached science in his own way.

Park, a man who almost became a medical missionary, saw it as a means to a larger end; he saw it as a tool to relieve suffering.

Avery was driven and obsessive. Part artist and part hunter, he had vision, patience, and persistence.

Paul Lewis was a romantic, and a lover. He wanted. He wanted more and loved more passionately than Park or Avery.

1968, and 2009. First, all five came in waves. (A few scientists argue that the difference in lethality between 1918’s first and second waves mean that these were caused by different viruses, but evidence showing otherwise seems overwhelming. For one thing, exposure to the first wave provided as high as 94 percent protection against the second wave, far better protection than the best modern vaccine affords, and that’s just one piece of the evidence that the same virus caused both waves.)

So the final lesson of 1918, a simple one yet one most difficult to execute, is that those who occupy positions of authority must lessen the panic that can alienate all within a society. Society cannot function if it is every man for himself. By definition, civilization cannot survive that. Those in authority must retain the public’s trust. The way to do that is to distort nothing, to put the best face on nothing, to try to manipulate no one. Lincoln said that first, and best. A leader must make whatever horror exists concrete. Only then will people be able to break it apart.